EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: Director, District of Columbia Department of Health Care Finance Office of the Health Care Ombudsman and Xxxx of Rights One Judiciary Square 000 0xx Xx. X.X., Xxxxx 000 Xxxxx Xxxxxxxxxx, X.X. 00000 0 (000) 000-0000, (000) 000-0000 Fax: (202) 000- 0000 If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: Commissioner, Department of Insurance, Securities and Banking 0000 Xxxxx Xx. X.X., Xxxxx 000 Xxxxxxxxxx, X.X. 00000 (000) 000-0000 Fax: (000) 000-0000 A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. CareFirst BlueChoice, Inc. [Signature] SAMPLE [Name] [Title] CareFirst BlueChoice, Inc. 000 Xxxxx Xxxxxx, XX Xxxxxxxxxx, XX 00000 000-000-0000 An independent licensee of the Blue Cross and Blue Shield Association ATTACHMENT B DESCRIPTION OF COVERED SERVICES The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. It is important to refer to the Schedule of Benefits to determine the percentage of the Allowed Benefit that CareFirst BlueChoice will pay and any specific limits on the number of services that will be covered. The Schedule of Benefits also lists important information about Deductibles, the Out-of- Pocket Maximum, and other features that affect Member coverage, including specific benefit limitations. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. CareFirst BlueChoice, Inc. [Signature] SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, an...
EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process relating to an Adverse Benefit Determination shall have the opportunity to file a complaint with the United States Office of Personnel Management within one (1) year of the date of receipt of the decision. The complaint may be sent to: MSPP External Review National Healthcare Operations U.S. Office of Personnel Management 0000 X Xxxxxx, XX Washington, DC 20415 Telephone: 000-000-0000 Facsimile: 000-000-0000 Email: xxxx@xxx.xxx Information concerning external review may be found on the U.S. Office of Personnel Management website: xxxx://xxx.xxx.xxx/healthcare-insurance/multi-state-plan- program/external-review/. The U.S. Office of Personnel Management’s jurisdiction for external review purposes encompasses appeals concerning medical judgments, contractual disputes and rescissions. In instances where an enrollee is appealing an adverse decision in an expedited (urgent) case, the enrollee may file his or her appeal simultaneously with CareFirst and the U.S. Office of Personnel Management. Group Hospitalization and Medical Services, Inc. [Name] [Title] Group Hospitalization and Medical Services, Inc. doing business as CareFirst BlueCross BlueShield (CareFirst) 000 Xxxxx Xxxxxx, XX Xxxxxxxxxx, XX 20065 000-000-0000 An independent licensee of the Blue Cross and Blue Shield Association ATTACHMENT B DESCRIPTION OF COVERED SERVICES The services described herein are eligible for coverage under the Agreement. CareFirst will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member. It is important to refer to the Schedule of Benefits to determine the percentage of the Allowed Benefit that CareFirst will pay and any specific limits on the number of services that will be covered. The Schedule of Benefits also lists important information about Deductibles, the Out-of- Pocket Maximum, and other features that affect Member coverage, including specific benefit limitations. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. Group Hospitalization and Medical Services, Inc. [Signature] [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–14 3 Pediatric Vision Services B–19 4 Adult Vision Services B–21 5 Inpatient Hospital Services B–22 6 Skilled Nursing Facility Services B...
